HIV in correctional settings

Inmates in jails and prisons across the United States (US) are disproportionately affected by multiple health problems, including HIV, other sexually transmitted infections (STIs), tuberculosis (TB), and viral hepatitis. Each year, an estimated one in seven persons living with HIV pass through a correctional facility. Most of them acquired HIV in the community, not while they were incarcerated. Compared with those who have not been incarcerated, incarcerated populations have more risk factors that are associated with acquiring and transmitting HIV, including injection drug and other drug use, commercial sex work, untreated mental illness, and lower socioeconomic status.

The numbers

More than two million people are incarcerated in the US. At the end of 2010, 1,612,395 persons were in state and federal prisons. At midyear 2010, 748,728 persons were in local jails.

Men and women of color—particularly Black men and women—are disproportionately represented in the US correctional system.

· In 2010, Black males had an imprisonment rate that was nearly 7 times that of white males and almost 2.5 times that of Hispanic/Latino males.

· That same year, Black females had an imprisonment rate that was nearly 3 times that of white females and almost 2 times that of Hispanic/Latino females.

In 2008 (the most recent year for which this information is available), 20,449 state prisoners and 1,538 federal prisoners (total, 21,987)—1.4% of the total prison population—were reported to be living with HIV or AIDS. Of the male inmates, 20,075, or 1.3 % were known to be living with HIV, compared with 1,912 female inmates, or 1.7%, who were living with the virus.

In 2007 (the most recent year for which this information is available), the rate of confirmed AIDS cases among state and federal prisoners was about 2.4 times the rate in the general US population. At year-end 2008, an estimated 5,733 inmates in state and federal prisons had confirmed AIDS. Of the 120 AIDS-related deaths in state prisons in 2007, nearly two-thirds, or 65%, were among Black inmates, compared with 23% among white inmates and 12% among Hispanic/Latino inmates.

Prevention Challenges

HIV Testing

The correctional setting is often the first place incarcerated men and women are diagnosed with HIV and provided treatment. These settings are ideal for reaching persons who have HIV, other STIs, TB, and viral hepatitis, as well as for providing at least initial treatment and care for persons with these infections. They also offer an opportunity to provide risk-reduction interventions that help prevent infection among those at highest risk. Yet, correctional staff and health care providers in jails and prisons frequently confront challenges related to

· implementing testing, treatment, and prevention programs in these facilities; and

· providing effective linkages to care and support services that sustain clinical benefits for prisoners after their release.

The Centers for Disease Control and Prevention (CDC) recommends HIV testing as part of routine medical care. In correctional settings, CDC recommends that HIV screening be provided upon entry into prison and before release and that voluntary HIV testing be offered periodically during incarceration. Testing has both individual and public health benefits, given the importance of getting early HIV care and the increased risk of HIV transmission among persons who do not know they have HIV. Although HIV testing is practical and acceptable in jails and prisons, inmates commonly are hesitant to be tested for a number of reasons, including

· fear of a positive diagnosis and the potential stigma associated with it; and

· concern that medical confidentiality will not be maintained.

Logistical, legal, and financial restrictions also have impeded HIV testing in correctional settings. Some of these logistical constraints—such as rapid turnover in jail inmates—have been addressed by using rapid HIV tests and testing within the first 24 hours after incarceration. Some correctional systems may be reluctant to provide HIV testing because it could mean increased laboratory and medical costs. Health care providers in correctional settings may face unique confidentiality and reporting requirements; they should be familiar with their local and state public health confidentiality laws and incorporate them into the HIV testing program.

Other HIV Prevention Interventions

In addition to HIV testing, CDC recommends that HIV education and prevention counseling be made available to inmates in correctional facilities. These programs should address risk inside and outside of the correctional setting. Prevention education programs delivered by peer educators are particularly effective in establishing the trust and rapport needed to discuss sensitive topics related to sexual practices, substance use, and HIV. Providing condoms and clean syringes to sexually active persons is an integral part of HIV prevention interventions outside prisons, but most US prisons and jails specifically prohibit the distribution and possession of these items. Although sex and substance use are forbidden in jails and prisons, the reality is that some incarcerated men and women have consensual or forced sex and that some use illicit drugs.

All inmates with HIV should have access to appropriate HIV medical care and treatment in addition to prevention counseling and, before release, should receive discharge planning and linkages to medical care in the community to ensure the continuity of HIV care and treatment. Such planning is crucial to sustain effective local HIV control efforts within the communities inmates return to.

People who are incarcerated are at increased risk for acquiring and transmitting HIV and other infections. Correctional health, public health, and community-based organizations need to improve HIV prevention and care for incarcerated populations through 1) routine HIV screening and voluntary HIV testing within prisons and jails and 2) other effective prevention strategies, including those that address inmates’ transition back into the community. Correctional institutions can be important partners in preventing and treating HIV to protect and improve inmate and community health.